Developmental Assessment Tools

With the diagnosis of a neurosurgical condition, often comes the awareness of potential or realized developmental delays. A comprehensive approach to assessment includes a family history, developmental observations, comprehensive neurological assessment, and developmental screening. Selected screening tools can aid in early identification of developmental delays.

There are few currently available screening tools that are equally accurate in detecting developmental delays in speech, language, fine and gross motor activities, and emotional and intellectual development. It is recommended that developmental skill attainment not be based on any one assessment tool.

When administering a developmental assessment tool, knowledge of the child’s neurological condition is important for interpreting the results. For instance, a child that shows language delays may also have a hearing impairment, which will skew the language assessment. Obtaining a standardized score may also depict the child’s developmental abilities, and guide the nurse in describing to the family developmental strengths and weaknesses. Tools should be used as only a component of developmental surveillance and part of a continuous comprehensive approach that includes the parent(s) as partners with professionals.

The goal of a comprehensive developmental approach in the hospital or outpatient setting is to determine the most appropriate developmentally based neurosurgical care for the patient. Treatment for identified needs can be better directed toward the developmental age of the child, which, if different from the chronological age, will impact the assessment and patient care of the child. This developmental information can guide the nurse in planning for the child’s home care, including targeted resources such as early intervention services, adapted educational plans, rehabilitation and therapy services.

Diagnostic Imaging and Testing in Neurological Assessment

Diagnostic tests and procedures are vital tools that help physicians confirm or rule out the presence of a neurological disorder or other medical condition. Advances in medicine, technology, and pharmacology have contributed to safer outcomes for children who may need sedation for diagnostic tests. Imaging or other tests may be performed to obtain a baseline for future studies.

In general, radiographic or digital imaging is looking at brain structure, while other diagnostic tests like electroencephalogram (EEG), single photon emission computed tomography scanning (SPECT), nuclear medicine scans, and Wada tests are evaluating specific functions of the brain. Positron emission tomography (PET) scans look at metabolic function and utilization of glucose by the brain. Newer technologies allow for the evaluation of cerebral blood flow and brain perfusion. Some tests serve both diagnostic and therapeutic outcomes.

Neurological examinations
Neurological examination assess your motor and sensory skills, the functioning of cranial nerves, hearing and speech, vision, coordination and balance, mental status, and changes in mood or behavior, among other abilities. Diagnostic tools including a tuning fork, flashlight, reflex hammer, ophthalmoscope, and needles are used to help diagnose:

• brain tumors
• infections such as encephalitis and meningitis
• Parkinson’s disease
• Huntington’s disease
• Amyotrophic Lateral Sclerosis (ALS)
• epilepsy.

Some tests require the services of a specialist to perform and analyze results.

Electroencephalography (EEG)

Electroencephalography, or EEG, monitors brain activity through the skull.  EEG is used to help diagnose certain seizure disorders, brain tumors, brain damage from head injuries, inflammation of the brain and/or spinal cord, alcoholism, certain psychiatric disorders, and metabolic and degenerative disorders that affect the brain. EEGs are also used to evaluate sleep disorders, monitor brain activity when a patient has been fully anesthetized or loses consciousness, and confirm brain death.

This painless, risk-free test can be performed in a doctor’s office or at a hospital or testing facility. Prior to taking an EEG, the person must avoid caffeine intake and prescription drugs that affect the nervous system. A series of cup-like electrodes are attached to the patient’s scalp.  These electrodes (also called leads) are small devices that are attached to wires and carry the electrical energy of the brain to a machine for reading.

 

PET Scanning (Positron Emission Tomography)
Disease is a biological process, beginning long before we are aware of it. Mobile Positron Emission Tomography (PET), allows doctors to view the organ systems of our body and how they are functioning. Physicians can see how the body's cells are functioning and the exact location of a disease.

PET is an imaging procedure that gives information not available through CT, MRI, x-ray, blood test or physical examination. PET is an invaluable clinical test for cancer, heart disease and neurological disorders, and is used more and more to diagnose patients with these serious afflictions.

• In neurology, PET is able to detect early signs of Alzheimer's, Parkinson's and Huntington's diseases, epilepsy and other disorders, even before some symptoms occur, making a critical difference in their treatment and management. PET detects the onset of Alzheimer's disease two to three years before any other diagnosis can be made, and in the case of hereditary Alzheimer's, PET can detect the disease before symptoms occur.
  
  
• PET is a safe and painless procedure, which typically takes about one or two hours to complete. Patients are injected with a small amount of non-dangerous radioactive sugar, and then rest for about an hour to wait for the body to process the sugar. In the mobile PET scanning room, the patient lies on a table that slowly passes through the scanner.

 

Importance of Neurological Assessment

Serial, consistent, and well-documented neurological assessments are the most important aspect of nursing care for the pediatric neurosurgical patient. Subtle changes in the neurological assessment may first be noted by a bedside nurse. Keen observation skills and the ability to extract information about a patient’s baseline level of neurological function from the parents or primary caregivers are essential. The nurse’s response to assessment changes is essential to the prevention of secondary neurological sequelae and other complications associated with neurological disorders. These potential complications include, among others, inability to protect the airway, immobility, endocrine disorders related to central hormonal dysregulation, impaired communication, and behavioral issues.
It is understood that children are not always under the care and custody of their parents. However, the term “parent(s)” is intended to include family members who have custody of a child, foster parents, guardians, and other primary caregivers.

A neurological assessment includes several exams, tests and procedures which are used to make the diagnosis of nervous system diseases. So what can you expect when undergoing neurological evaluations? Every condition is different and therefore the assessment will vary considerable. However, there are some general tests and exams which many neuro patients will undergo. Here is an overview of some of these common parts of a neuro assessment.

Nursing Approach to Neurological Assessment
Neurological assessment should be an integral part of the entire physical assessment. The approach to neurological assessment should be systematic and include pertinent health history, for example coexisting conditions, the developmental status of the child, the nature and extent of the injury or surgery performed, and potential complications. Sources of this information include the verbal report or patient record and the neurosurgeon, neurologist, or other medical providers. Nurses must be aware that other physical and developmental disorders not directly associated with the neurological condition, such as renal, cardiac, or pulmonary, may also affect the patient’s long-term prognosis and ultimate quality of life. Care planning should be a team approach that involves the parents and the multidisciplinary team to assure optimal outcomes. Factors that impact the assessment will be the age of the child, the family dynamics, the nature of the child’s illness, the setting in which the assessment takes place, and input from other member of the multidisciplinary team.